MEDICARE: KEISHLA DE JESUS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator	27000	PR

General Provider Information

NPI Number	:	1497142822
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEISHLA DE JESUS

Provider Business Mailing Address
First Line	:	8285 46TH AVE
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32967-5689
Country	:	US
Telephone Number	:	772-257-1346
Fax Number	:

Provider Business Practice Location Address
First Line	:	8285 46TH AVE
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32967-5689
Country	:	US
Telephone Number	:	772-257-1346
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2015
Last Update Date	:	04/23/2015

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